Peak child and the graying population of the developing world

It's not just the industrialized world that's seeing a graying population. We …

What are the biggest challenges of global health? Typically, we think in terms of things like vaccines and basic sanitation, which are issues in the poorest nations. But a panel on the topic, hosted by the Lindau Nobel Laureates Meeting, painted a very different picture. The majority of the world's nations now look very much like the industrialized world, with small family sizes and life expectancies of around 70 years and up. Many of them, however, have gotten there without the sort of economic growth that preceded a graying population in the industrialized world. As a result, one of the big challenges in global health is now caring for an older population on a low budget.

The trends were driven home by the Karolinska Institute's Hans Rosling, who relied on graphs that can be created using a site called Gapminder.org. These track various demographic features of most of the world's nations, such as life expectancy, GDP per capita, etc. The plots can be rolled forward and backward in time, and individual countries can be traced as changes occur. Rosling used a series of these graphs to demonstrate a number of points about the trends that have taken place over the past century.

Rosling started with a plot of family size vs. life expectancy; in the 1960s, the industrial world occupied the upper-left corner of the graphs below, with small families and longer life expectancies. Track forward to today, and all but a few African countries (many of which are suffering from HIV epidemics) have made their way to the upper left of the graph. Now, as he pointed out, Bangladesh is where Germany was in the 1960s. For adults, the greatest risk of death is in traffic accidents; for children, it's drowning. "The world has gotten better," Rosling declared. "It's bullshit to say otherwise."

A century ago, only the most industrialized nations were beginning to see increased life expectancy.

Outside of Africa, almost all countries now see smaller families and much longer life expectancies.

The net result is that we reached what he termed "peak child" in about 2005. The world used to be dominated by the population in the lowest age brackets. That's now starting to shift—with the biggest chunk of the population now being in adolescence. The world isn't getting gray just yet, but, as Rosling put it, "we now just have adult population growth."

But that's going to pose some significant challenges, since Bangladesh hasn't tracked Germany exactly. If you plot life expectancy against GDP/capita, you'll see that Bangladesh's growing life expectancy hasn't been paralleled by economic growth. Similar things are happening all over the globe; Vietnam now has a life expectancy that US had during Vietnam war, but its purchasing power is where the US was during its Civil War. "We've never had a point in our history where countries have modern life expectancy illnesses without the income to support treatments," Rosling concluded.

This isn't to say that diseases related to abject poverty weren't a problem; there are certainly areas of the globe with failed governments or persistent poverty that don't have the basic nutrition and sanitation to see these sorts of extended life expectancies. But, in general, those have become the exceptions.

Making medicine cheaper

With that as an introduction, the entire panel looked at how this might influence global health over the next few decades. Unni Karunakara of Médecins Sans Frontières, summarized Rosling's talk as follows: there's a difference between spending on health and spending on essential healthcare. More and more of the world is starting to do the former, but it's making for a bumpy transition. India, he said, still spends 15 times its health care expenditures on its military. If it decided to flip those around, the system couldn't handle the large influx of funds; there simply aren't enough nurses to handle that much additional care.

The low funding in much of the developing world actually helps in some ways. Karunakara argued that corruption hasn't become a problem when it comes to the delivery of medicine since there's not enough money to attract it. That's not to say that these places are spending so little that they're not getting anything out of their healthcare spending. Karunakara said India gets more bang per buck than the US, but there's simply not as many bucks there.

Of course, this highlights the fact that the US spends a lot on its healthcare without a clear benefit compared to a number of other countries that spend less. One of the panelists, James Vaupel of the Max Planck Institute for Demographic Research, didn't think this was a big deal. "The US already has more than one car per driver," Vaupel noted. "What are you going to do with that money anyway? You spend it on health care by choice."

In the end, the panel argued that both types of economies could benefit from some of the trends that are being driven by the graying population of the developing world, mostly in terms of a new focus on research. Rosling gave one example, saying that an implant used during cataract surgery (which is primarily performed on older populations) used to cost hundreds of Euros; researchers in India figured out how to make it for €0.80. He expects to see more developments like that, as he noted that middle-income countries have started pooling their resources (India, for example, is funding work at his home institution, the Karolinska).

There are limits to this sort of progress, however. The complex regiments of small-molecule drugs that often treat chronic diseases in the developed world don't always translate well to places without amenities like reliable refrigeration. Both Rosling and Karunakara feel that innovation in small molecule drugs is often the best way forward, but believe that the patent system has become an impediment here.

R&D in this area is hugely expensive, Rosling said, and a patent is often enough to keep anyone from working on improvements or related chemicals for nearly 20 years. Karunakara suggested that patent pools, in which a company licenses its work to all participants for a smaller profit up-front, could help alleviate this bottleneck. Rosling countered that we needed new, clever incentives for pharmaceutical companies that didn't involve patents (although he didn't specify what they might look like).

Overall, the panel suggested there were two inherent tensions to the demographic trends. One is that economic growth is providing greater access to healthcare even as it increases the incidence of the chronic diseases of wealthy nations. Overall, as Vaupel noted, this is improving the quality of life, and allowing people to remain productive longer, which could help us overcome the challenges of caring for an increasingly aging population. Unfortunately, nobody wants to work longer than they already do, so these challenges remain largely unmet.

A German minister, Georg Schütte, was on hand, and he said that some of the issues can be handled with simple policy changes. In response to demographic changes, the German government is closing schools in the former East, and focusing on programs that made life better for those in their 60s and 70s.

But most governments don't have Germany's resources to use to address their problems, and health care will be evolving under pressure from potentially catastrophic events. Vaupel, who was generally an optimist, noted that significant climate change and global epidemics were possible, and could trigger wars or economic collapse in their wake. But the optimist in him returned when he noted, "The 20th century was not a good time for Germany," as it went through two wars and an economic collapse. Somehow, throughout that time, its life expectancy went from about 40 to over 80.

The message seemed to be that, even if we make a mess of things, we may still manage to make the world a better place.